Local Control and Local Variation

Kindly supported by

The move towards greater local autonomy in the NHS offers new possibilities for services

that are specifically targeted at local needs. Locally varied services will be necessary

to make the health service more effective and efficient in the years ahead. But there are

fears that greater local spending and decision-making power will undermine the national

character of the NHS, amid public concern about ‘postcode lotteries’. This study presents

the findings of a piece of original research carried out in conjunction with Ipsos MORI

examining public views about variation in the NHS. Will people respond more positively

to variation in services if they feel they have control over the decisions that are made in

their area? What accountability mechanisms should be introduced to make sure that the

health service meets public expectations? And who should take the lead in making tough

decisions about possible service cutbacks?

These questions have been made even more urgent by the dramatic downturn in the

economy. Real-terms cuts in public service budgets are now unavoidable and will present a

huge challenge for health services at a time when health costs are rising. This study shows

that while people say they are in favour of a nationally based NHS, in practice the public

supports locally tailored services. The key to allaying people’s concerns about changes to

local services is making sure that decisions are transparent and fair.

This report is part of the ongoing SMF Health Project.

£5.00 Social Market Foundation11 Tufton Street | Westminster | London SW1P 3QBPhone: 020 7222 7060 | Fax: 020 7222 0310 www.smf.co.uk David Furness and Barney Gough

What do the Public Think?

LOcAL cONTROL ANd LOcAL vARIATION IN

THe NHS

SMF Health Project

Copyright © Social Market Foundation, 2009

£5.00

David Furness and Barney Gough


LocaL conTroL and LocaL variaTion in

The nhS

Kindly supported by

SMF Health Project

FirSt PuBliSHeD By The Social Market Foundation, May 2009

11 Tufton Street, London SW1P 3QBcopyright © The Social Market Foundation, 2009The moral right of the authors has been asserted. all rights reserved. Without limiting the rights under copyright reserved above, no part of this publication may be reproduced, stored or introduced into a retrieval system, or transmitted, in any form or by any means (electronic, mechanical, photocopying, recording, or otherwise), without the prior written permission of both the copyright owner and the publisher of this book.

tHe Social Market FounDationThe Foundation’s main activity is to commission and publish original papers by independent academic and other experts on key topics in the economic and social fields, with a view to stimulating public discussion on the performance of markets and the social framework within which they operate.

The Foundation is a registered charity and a company limited by guarantee. it is independent of any political party or group and is financed by the sale of publications and by voluntary donations from individuals, organisations and companies. The views expressed in publications are those of the authors and do not represent a corporate opinion of the Foundation.

cHairMandavid Lipsey (Lord Lipsey of Tooting Bec)

MeMBerS oF tHe BoarDviscount (Tom) chandosGavyn daviesdavid edmondsdaniel FranklinMartin ivensGraham MatherBrian Pomeroy

Directorian Mulheirn

DeSiGn anD ProDuctionSoapBox

PrinteD Byrepropoint

conTenTS

contentS acknowledgements 4

introduction 5

The results – opinion polling 12

Qualitative work – discussion groups 15

conclusions 32

SociaL MarKeT FoUndaTion

4

acknowleDGeMentS

The authors would like to thank Jonathan nicholls and chloe Smith

at ipsos Mori, without whom this publication would not have been

possible.

We would also like to thank ian Mulheirn at the SMF for his input

to our work.

The SMF health Project is kindly supported by Bupa, nhS

connecting for health, Pfizer and Standard Life healthcare.

DiSclaiMerWhile this report draws on material supplied by ipsos Mori the

views expressed below are solely those of the authors.

inTrodUcTion

5

introDuction

The SMF health Project has examined many aspects of the future

of health services in this country. at the heart of our research has

been the future of commissioning – how Primary care Trusts (PcTs)

are likely to develop given current policy trends, and the risks

and opportunities this presents. The move towards greater PcT

autonomy embodied in the World class commissioning Framework

offers a range of fresh possibilities for the nhS to design services

that are specifically targeted at local needs, with new and innovative

providers emerging in response to the different needs identified

by commissioners. But there are fears that greater local spending

and decision-making power will undermine the national character

of the nhS. This is a particularly trenchant criticism in the context

of public concern about “postcode lotteries” in the nhS. however,

while postcode lotteries are a common feature of the public debate

on health, they are relatively poorly understood. With ipsos Mori,

we examined public views about variation in the nhS, and explored

whether trade-offs could be made over local variation and local

control. Will people respond more positively to variation in services if

they feel they have control over the decisions that are made in their

area? What accountability mechanisms should be introduced to

make sure that local health services meet the public’s expectations?

These questions have been made even more urgent by the

dramatic downturn in the economy. There are fears that there will

be real-terms cuts in public service budgets – a huge challenge for

health services at a time when every country in the developed world

has seen health costs rise year on year for several decades. We do

not yet know what the downturn will mean for the nhS. however,

now is the time to explore the options available for making the

tough decisions that we face.

Presented below are the results of the polling and discussion

groups used to examine these questions, and spell out some policy


6

implications for the long-term future of the health service. These

insights will be at the heart of the forthcoming final report of the

SMF health Project.

MetHoDoloGy

We worked with ipsos Mori to develop opinion poll questions to

explore what people think about the nhS. These were focused on

three distinct areas – local variation, public involvement and the

future funding of healthcare.

1. local variation

it is clear that people are exercised by the idea that treatments

might not be available in every area. headlines like those below

resonate with the general public because there is a strong sense

that treatments should not be dependent on where one lives:

“Postcode lottery for cancer wonder drug”1

“Patients denied life-saving drug even after health watchdog

approval”2

however, these headlines do not necessarily indicate that people

think that new treatments should be introduced only if their

availability can be guaranteed in every area. nor do they reveal

how people view the substantial variation in healthcare between

areas that is not subject to the same level of media scrutiny as

access to new and expensive medicines tends to be. a King’s Fund

analysis of variation in spending between PcTs found significant

differences that cannot be explained by differences in need. For

example, islington PcT (adjusting for need) spends £332 per head

of population on mental health compared with £114 per head by

1 d. Wilkes, “Postcode lottery for cancer wonder drug”, Daily Mail, 10 april 2006.

2 “Patients denied Life-Saving drug even after health Watchdog approval”, Daily Mail, 9 January 2008.

LocaL conTroL and LocaL variaTion in The nhS

7

east riding of Yorkshire PcT, and the proportion spent on mental

health ranges from 8.7% to 25% of PcT budgets.3 What does

the public think about the pros and cons of deeply embedded

local variation in a supposedly national health service? This is a

particularly important topic given the general trend of health policy.

The nhS operating framework for 2008/9 shows that national

targets still form an important part of healthcare policy. it describes

a set of “key non-negotiable national nhS targets”4 for local PcTs.

These include access targets such as the 18-week maximum waiting

time as well as those aimed at specific diseases, such as the extension

of the nhS bowel cancer screening programme. This would seem

to be in line with the goal set out by aneurin Bevan in 1948 that

the nhS should “universalise the best”5 – creating a truly national

health service. But recent nhS reform has seen unprecedented

devolution of money and authority to PcTs at a local level. The

vision set out in the World class commissioning Framework aims

for a “new nhS – locally driven”. it describes how commissioning

will be “developed, articulated and owned by the local nhS,

with a strong mandate from local people and other partners”.6 in

practice this will mean ever more variation between different areas.

While PcTs are charged with designing a range of services around

the needs of local people, it is not at all clear that this fundamental shift

in the nature of the nhS has been fully understood by the public. nor

is it clear how national standards and targets will evolve in response to

the increasing power of local commissioners who have been told to

“look outwards not upwards”7 – in other words becoming accountable

3 J. appleby and S. Gregory, Local Variations in Priorities: An Update (London: King’s Fund, 2008).

4 department of health, NHS Operating Framework 2008–2009 (London: hMSo, 2008).

5 aneurin Bevan, quoted in r. Klein, The New Politics of the NHS: From Creation to Reinvention

(London: radcliffe, 2006), 19.

6 “World class commissioning: vision”:www.dh.gov.uk/en/Publicationsandstatistics/Publications/

PublicationsPolicyandGuidance/dh_080956.

7 ibid.


8

not to central government but to local people. This tension between

national standards and increasing levels of local variation is at the heart

of the debate about the future of healthcare in the UK.

2. PuBlic involveMent

it is sometimes argued that the public should have a much more

direct involvement in the design and running of health services. This

debate goes back to the founding of the nhS, when herbert Morrison

supported local government control of healthcare only to be

overruled by aneurin Bevan’s preference for a single national hospital

service.8 Since the inception of the nhS, providers of healthcare have

generally been more accountable to central government than to local

people, in large part because of the national funding mechanisms

of the health service. There have been a number of systematic

attempts to involve people in the design and running of health

services, and in recent years there have been steps taken to make

providers more accountable to patients. a good example of this is

the elected membership of Foundation Trust boards. however, since

the introduction of a purchaser–provider split, with PcTs holding

budgets and commissioning services, it is clear that accountability

mechanisms are not necessarily adequate to make sure that the views

of local people are properly represented. community health councils

no longer exist, and it is not clear that Local involvement networks

(LinKS) are having much impact in affecting decisions at a local level.

it is in this context that some have advocated a radical

overhaul of accountability in the nhS to bridge the gap between

commissioners and local people. The Liberal democrats have

advocated the introduction of locally elected health boards as a

way of establishing real local control.9 The Picker institute has argued

that the democratisation of PcTs is inevitable as the significance

8 c. Webster, The National Health Service: A Political History (oxford: oxford University Press, 2008).

9 Empowerment Fairness and Quality in Healthcare (London: Liberal democrats, 2008).


9

of PcT budgets and commissioning duties becomes more widely

understood.10 But accountability for decision-making and local

involvement in those decisions does not necessarily equate to

democratic control. democratic mechanisms do not necessarily result

in a true reflection of the views of local people, and there are practical

constraints too – do people actually want to get involved in decisions

about healthcare?

We wanted to explore whether the public is in fact interested in

being involved in decision-making at a local level, and whether there

is a relationship between greater local involvement and greater local

variation – would people accept difference between areas if they felt

fully involved in decisions about where to put resources? it is important

not only to consider the intrinsic opportunities and threats of greater

local involvement in healthcare, but also to understand how this fits

with the wider context of nhS reform. as discussed above, the drift

of health policy is towards ever greater variation between areas, with

ever greater control exercised by local PcTs. is it possible to make sure

that decisions leading to greater variation have legitimacy through

involvement mechanisms that do not necessarily add up to the kind

of democratic control proposed by the Liberal democrats?

3. FunDinG HealtH ServiceS into tHe Future

in conjunction with the questions exploring variation and the extent

to which people wish to be involved in decision-making, we also asked

about how the health service should raise money in the future. While

some of the more extreme claims about cost increases in healthcare

seem far-fetched,11 two things are clear. First, that the general trend

of health spending is upward and, second, that the public finances

are in a perilous state. To set decisions about future financing for

healthcare in context, derek Wanless’s 2002 report for hM Treasury on

10 Accountability – Public Views and What to Do About Them: Submission to the Local

Government Association Health Commission (oxford: Picker institute europe, 2008).

11 For example, Professor Karol Sikora’s prediction of a £50bn UK market for cancer drugs.


10

the future of healthcare suggested that even in the most optimistic of

scenarios, health services would require average real-terms increases

in spending of 4.4% up to 2012/13 if we want to see continued

improvement. his least optimistic scenario suggested that spending

would need to rise by 5.6% per annum.12 and even before the current

economic crisis, many experts had predicted that demand for, and

the costs of, health services would rise at a greater rate than our

ability to pay for them through taxation. one authoritative report, an

analysis conducted by nera and Frontier economics, suggested that

the nhS will face a funding gap of £11 billion by 2015 if current (up to

2010) levels of annual spending increases are maintained.13

in the current economic climate, and with the poor prognosis

for the public finances over the next decade, it is inconceivable that

the nhS will enjoy funding increases of 4.4–5.6% per annum over the

coming years. We are left, then, with options for the medium-term

future of the nhS that are not politically attractive:

• a decline in the standard of nhS care;

• significant increases in taxation;

• significantly increased private payments for healthcare;

• a radical reassessment of what the nhS will and will not

provide;

• heavy real-terms cuts in other department budgets to

protect health spending.

at this stage it is not possible to say which of these options, either

alone or in combination, will be required to maintain the publicly

funded health system in the future. What is clear is that government

needs to engage more with the public to acknowledge the difficult

choices that lie ahead, and to understand how their views about

12 d. Wanless, Securing Our Future Health: Taking a Long Term View (London: hM Treasury, 2002), 75.

13 e. Bramley-harker et al., Mind the Gap: Sustaining Improvements in the NHS Beyond 2008

(London: Bupa, 2006).


11

financing fit with their views about service development in general.

There are few clear-cut answers to the challenge created by a time of

scarcity in public resources. and, given the important place of the nhS

in British society, we need more than ever to maintain public support

for a system that enshrines significant values of universal access to

healthcare regardless of income. These are questions of politics,

not just of policy. Furthermore, the challenges of local variation and

local involvement outlined above are not irrelevant to questions of

funding. Ultimately, we are asking people how they would prefer

decisions to be made about the future of health services. Given that

the economic downturn is likely to preclude significant funding

increases for healthcare for many years to come, there is an urgent

need to address these questions.

oPinion PollinG anD DiScuSSion GrouPS

To investigate the three areas described above, we conducted an

omnibus survey questioning 998 english adults.14 The results are

explained below. The intention of this initial survey was to elicit “top

of mind” responses – the instinctive reaction of individuals when

questioned about their views. Using these results, we then developed

a series of discussion groups to explore in greater depth the findings

from the opinion poll and to understand better what informs the

views people hold, what those views mean in practical terms for the

nhS and what the implications are for policymakers. The results of

these discussion groups are presented below.

This research is neither exhaustive nor definitive. The questions

we asked do not address every aspect of the debates we hope to

illuminate. however, these results provide some useful insights for

the future design of health services, particularly in the context of the

changing demand-side pressures that have already been elucidated

14 ipsos Mori omnibus telephone survey, november 2008. Base: 998 english adults (18+)


12

by previous SMF health Project publications.15 notably, the opinion

poll data provides a keen sense of how the public approaches the

questions that we have defined as crucial for the future of health

services. The information gleaned from our discussion groups shows

how further debate might enable public opinion to develop, allowing

government and health service commissioners to make decisions

that both accord with the need to make tough choices and carry

support from the public.

tHe reSultS – oPinion PollinG

local variation in the nHSPerhaps unsurprisingly, polling uncovered a clear majority of people

in favour of nationally available treatments.

Figure 1: Most people want standard treatment available

across the country

Beneath the headline figure were some intriguing results. For

example, it emerged that 32% of black and minority ethnic (BMe)

15 d. Furness et al., SMF Health Project Background Papers (London: Social Market Foundation, 2008).

Thinking of the treatments that are available on the NHS,which of these statements most closely matches your opinion?

73%

23%4%

Don’t knowThe availability ofNHS treatmentsshould be based onlocal need rather than a ‘one size �ts all’ approach across the country

Treatments shouldonly be availableon the NHS if theyare available to everyone and notdependent on whereyou live

Ipsos MoriBase: 988 English adults (18+), November 2008


13

respondents are in favour of more locally tailored services compared

to 23% of people overall. however, the sample here was not large

enough to confidently attribute different values to this group.

Public involvementThere was a clear majority in favour of involving the public in

decisions about health services. only 20% of people do not think that

the public should be involved at all in decision-making; most people

argued for consultation, with the final decision to be made by health

professionals. a further 20% were keen to see much more active

involvement for the general public in shaping which nhS treatments

and services are available.

Figure 2: the public want to have a say

of course, one of the key challenges here is to understand what

people mean by “involvement”, and whether it is possible to translate

the desire for involvement into structures that will improve health

services. There are many potential models for public involvement in

health services, but what do people actually want?

Public want to have a say Thinking of how decisions about treatments and services should be made, which of these statements most closely matches your opinion?


73%

4%

Don’t know Decisions about which NHS treatments and

services are availableshould be made solely

by quali�ed health professionals and not

the general public

The general public should be much moreactively involved inshaping which NHStreatments and services are availableeg. deciding local priorities and allocating budgets

The public should be consulted on decisions

shaping which NHS treatments and servicesshould be available but

the �nal decisions should be made by quali�ed health

professionals

20%20%

5%

54%


14

Funding into the futureWe asked people how any potential shortfall in health budgets

should be made up. This does not reflect an ideological agenda

for changing the system of funding, but is a pragmatic view based

on the clear evidence that health budgets in the next decade will

be severely squeezed in comparison to the years of plenty that the

nhS has recently enjoyed.

Figure 3: no real consensus about how to address shortfall

We asked respondents about four options for supplementing

the nhS budget, including increasing taxes and introducing private

payments. We also attempted to distinguish between priority-

setting to save money led by government and that led by the

nhS. This was intended to demonstrate which group the public

expects to take the lead on decision-making about nhS priorities.

There has been a lot of focus on the perceived benefits of an

“independent” nhS, but our poll shows that many people believe

that the government has an important role to play. This distinction

is explored in greater detail later in this report.

How should NHS budget shortfalls be addressed?

73%

4%

Don’t knowTaxation should increase

NHS shouldprioritise

Individuals shouldcontribute

Government should prioritise

28%

30%

10%18%

13%



15

Unsurprisingly, there is little support for an increase in taxation,

and even less for individuals to contribute more to the costs

of their healthcare. however, the even split between support

for government-led priority-setting and that led by the nhS is a

real insight into how we should approach the challenges of the

future. as well as looking further into the distinction between

government and the nhS, what people mean when they refer to

“priority setting” is explored below.

Qualitative work – DiScuSSion GrouPS

The polling results above elicit headline findings, and give

quantitative results for the key questions. however, the bulk of

this research has been qualitative – seeking to understand why

people think as they do. To that end, we worked with ipsos Mori to

design a series of discussion groups to explore further the insights

generated from the quantitative work.

discussion groups are designed to take a group of people and

work with them through a variety of exercises that reveal the thought

processes behind different attitudes and values. Participants might

be distinguished by age, locality or socio-economic background to

help understand differences between the groups.

a key aim of this research was to understand in greater depth

divergent views about variation in care. The tension between

national and local control and the consequent variation in services

is at the heart of the political debate in healthcare, and is a key part

of the SMF health Project’s wider research into the future of the

nhS. consequently, it was judged that the discussion groups would

provide more insight if they were focused on different attitudes to

this key question about local variation in care. as such, we recruited

focus group attendees based on their responses to questions about

local control and national standards as well as their socio-economic

status.


16

Four discussion groups were conducted. Two of these groups

were made up of people who strongly agreed that nhS treatments

should be based on local needs. The other two groups were made

up of people who strongly agreed that treatments should only be

provided if they were available across the whole country. as well

as this attitudinal split, groups also comprised people of different

age and socio-economic status. This enabled an exploration of any

possible links between attitudes to local variation in health services

and other factors.

Group one: older (45+), low social grades (c2–e), local need

preferred

Group Two: Younger (25–35), high social grades (a–c1), local

need preferred

Group Three: older (45+), high social grades (a–c1), national

standards preferred

Group Four: Younger (25–35), low social grades (c2–e),

national standards preferred

The discussion groups were moderated by experts from ipsos

Mori. Quotations below are representative of the views expressed

in the groups.

why do people hold the opinions they do?We started by asking people to explain why they hold particular

views about the importance of local or national priorities.

at first sight, these appear to be very disparate sets of views.

however, this does not necessarily mean that there are radically

different values between the groups. on digging deeper, both

justified their views on the basis of fairness. however, fairness

means different things to different people.


17

Figure 4: we asked both groups to explain their views

These responses demonstrate the two very distinct approaches to

the principle that the nhS should be fair.

Figure 5: we then asked them to explain why this was important

73%

4%

Ipsos Mori

28%

30%

10%18%

13%

The ‘local targeting’ groups

“You need to utilise the resources in the areas where they are most needed”

“If you had an equal service you would probably get a mediocre service all over instead of very good services in some areas”

The ‘national consistency’ groups

“When the NHS came around it was the same treatment for everyone and I don’t think we should change that”

“I agree it has to be nationally , as the name stands. It can’t be any other way because there would be so much discrimination otherwise”

For the ‘local targeting’ group

driving principle is service where it is needed

so service based on need/needs analysis

For the ‘national consistency’ group

driving principle is equality

so everyone should have access to the same services

Key aspiration for both groups: the NHS should be ‘fair’

But ‘fairness’ interpreted very differently...

Ipsos Mori


18

applying fairness in practiceBut what does this mean in practice? The groups were taken

through an exercise designed to draw out a process of decision-

making that they would consider fair. Participants were asked to

put themselves in the place of an nhS funding committee in the

fictional country of “new Britannia”.

in new Britannia there is a core range of health services

delivered to a good standard that is available to everyone.

however, there are different health needs in different areas of

the country, with diabetes, respiratory disease and childhood

leukaemia particular problems in particular areas. The groups were

then offered a range of possible service improvements, with the

caveat that it is not possible to afford all of them. These ranged

from investing in reducing surgery waiting times to increasing the

resources available for specialist diabetes services. Some possible

improvements would have a national impact, while others would

be targeted at particular health issues. Participants worked together

New Britanniacore health

services and basicstrandards provided

throughout

Ipsos Mori

Region AHigh prevalenceof diabetes

Region BHigh prevalenceof respiratoryproblems

Region CHigh prevalenceof childhoodleukaemia

Raise National Stds

Nurse ratio

Ambulance response

Surgery waiting times

Specialist Services

Respiratory

Leukaemia

Diabetes

Figure 6: you are the nHS funding committee


19

to decide where resources should be targeted, by placing symbols

on a map. The aim of this exercise was to find out whether different

groups would choose to raise national standards or would target

areas of particular need.

all four groups prioritised investment in specialist services

aimed at specific health issues in particular areas before they

looked to invest in raising national standards of care.

This indicates that, in practice, everyone supports the idea that

resources should be specially targeted where the need is greatest.

But the environment created by the groups could be described as a

“postcode lottery”, with more money spent on particular treatments

in some areas than others. We asked the groups to consider the

impact of the decisions they had chosen to make. Their reactions

were particularly interesting.

The groups who had initially favoured local priorities were

happy with the decision they had made. They were comfortable

with the situation they had created, and could rationalise their

Respiratoryproblems

The ‘local targeting’ groups

The ‘national consistency’ groups

Childhoodleukaemia

Diabetes

Ipsos Mori

Figure 7: So how did the groups distribute the spending?


20

decision by explaining that services were where they were needed

most.

in contrast to this, the two groups made up of people who had

initially favoured national decision-making were unhappy with the

situation they themselves had chosen to create. a sample of their

reactions is set out below.

Figure 8: when we pointed out they’d created a ‘postcode lottery’

The quotation highlighted in figure 8 is taken from one of the

national standards groups. interestingly, although it was made clear

at the beginning of the task that specialist services would involve

improved services, the national standard group had not taken this

on board and justified their decision post hoc by saying that they

thought they were offering more services, but not better services.

clearly, these categories are not mutually exclusive. in many senses,

more services are better services – extra resources in one area

mean that people in other areas do not have access to the same

levels of care. it seems to be that some participants in the national

standards groups felt that a fair distribution of resources was one

in which every person has access to exactly the same services.

73%

4%

Ipsos Mori

28%

30%

10%18%

13%

The ‘national consistency’ groups were split

some thought they’d made a mistake - wanted to change their answer

some resolved this by distinguishing between more andbetter services - more services where needed fits with their definition of fair (equity) - better services does not

“If we actually thought that there were going to be specialists in this area, drugs only available in this area, then we would have voted completely di�erent... we thought we were just putting more people there. If you had mentioned only these people will get the better drugs, we would have thought di�erently.”


21

This is not the case in the nhS – hospitals are not evenly spread

throughout the country, for example. But there was still a sense

from these groups that the nhS should supply the same services

per head, without regard to areas of particular need. This sentiment

was expressed despite the fact that all groups elected to devote

specialist resources to areas of need rather than acting to raise

national standards.

what does this tell us?The quantitative work showed that there is a large majority

(approximately 3:1) in favour of national consistency rather than local

targeting in healthcare. however, it is clear that both sets of groups

based their answers on ideas of fairness. But, just as the theoretical

literature on equality in healthcare contains myriad different

definitions, so fairness means different things to different people.

ideas about what is fair are not necessarily well developed

or expressed coherently. This is not surprising, and is probably

reflective of the fact that most people do not spend their time

thinking about the fair use of resources in public services. But they

do have an instinctive reaction about what is fair and what is not.

Broadly, all groups were concerned that people have access to

healthcare services when they need them. For some, that meant

that services should be allocated according to need, while for

others it meant that services should be the same across the country.

it is probable that this actually reflects the same underlying value

– that treatment should be available wherever you are. however

some groups had considered the implication that this means that

very different services will be available in different areas. other

groups believed that fair access requires the same services across

the country – something that is clearly not the case in the nhS.

But there was also an instinctive acceptance by all concerned of

the need for equity and efficiency trade-offs. The exercise designed to


22

test their attitudes to variation started with the premise that only some

service improvements are affordable – we cannot provide everything

to everyone all the time. Some groups were more accepting of this

trade-off than others groups who saw the local variation this implies

as a challenge to the values they assume are at the heart of health

provision – that services should be the same everywhere.

however, even people who argue for national consistency (in

other words, the same services for everyone across the country) will,

when given the opportunity, allocate services based on need. We

believe that this has important implications for policymakers, as public

fears of a “postcode lottery” are more subtle than might first appear.

What can policymakers do in response to this insight? We know from

our groups that some people who have a strong belief in national

standards will choose what seems to them a “postcode lottery” if the

rationale behind variation is properly explained. This indicates that

opposition to variation might be overcome with a better process of

explanation and engagement with the public.

We were also interested to see whether greater local involvement

in resource-allocation decisions would make it more likely that local

variation in services would be accepted, or even valued.

local involveMent in HealtHcare DeciSion-MakinG

as noted above, there is a clear majority of people in favour of some

form of public involvement in decision-making in the health service

– only 20% felt that decisions should be made by professionals alone.

This is in line with the direction of policy in healthcare, which

attaches ever more importance to engaging with local populations

in designing health services.16 But what sort of people want to be

involved with health services, and to what extent?

16 For example, the department of health’s World class commissioning Framework


23

The discussion groups revealed some surprising views:

• the national standards groups were excited by the prospect

of local involvement;

• the local needs groups saw it as a last resort.

This could be taken as evidence that locally determined services

of the type favoured by local needs groups do not necessitate

public involvement. and different values are reflected here. The

national standards groups were keen to make sure that health

services reflect people’s priorities, whereas the local needs groups

preferred health services that were objectively designed around an

analysis of need.

Significantly, very few of the participants in any of the groups

wanted to be involved themselves. People would prefer the nhS

and the government to “get it right” without them. To explore these

views further, the groups were taken through another exercise,

asking in what service areas engagement is particularly important.

Figure 9: where do the public want to be involved?

73%

4%

28%

30%

10%18%

13%

Task: on what should the NHS engage the public?

Childhood ObesityHow should budget be split among

education, family training, activity programmes, etc.?

MRSA ReductionHow should budget be dividedregarding cleaning, education,

equipment etc.?

MidwiferyHow should budget be split amonghospital, community, and intensive

care services?

GP ServicesHow should budget be split among

funding extra doctors, extending hoursoffering extra services?

Cancer ScreeningWhich screenings are prioritised?

Which screenings are available to whom?

End of Life CareHow would budget be divided

between hospice care, in-patient care,complimentary services?

Ipsos Mori


24

where do people want to have their say?We asked each group to select two service areas, out of a choice

of the six set out in Figure 9, where they thought it would be most

important for people to have a say. Figure 10 shows how different

groups expressed their preferences.

Figure 10

local need/ older local need/

younger

national stds/

older

national stds/

younger

child obesity

MrSa

Midwifery

GP services

cancer screening

end of life

ipsos Mori

The moderators discussed with the groups the rationale for

their decisions, and identified the criteria listed below:

Where people feel the public should be involved:

• where an issue affects a lot of people a lot of the time

(GP services);

• if there is a feeling that it’s an area where the nhS is

currently getting it wrong (MrSa);

• where people feel they have a better idea of what is

needed than service providers (GP access);

• where a solution requires public buy-in to be successful

(tackling childhood obesity).


25

Where people feel the public does not need to be involved:

• where the nhS is currently getting it right (based on good

personal experience or word of mouth testimony);

• where decisions should be objectively made and clinically

based (such as cancer screening).

This might not be a set of criteria that most health managers would

be happy to apply to decision-making in their area. But it reflects a

general feeling from the groups that people think it is most important

to be consulted when things are not going well. however, they are

unwilling to devote much time to being consulted – a typical comment

from one participant was: “oh God no, it’s too much work.”

other concerns about public involvementas identified at the start, all groups prioritise fairness in their approach

to the nhS, although this feeling is expressed differently. Because of

this, all groups were concerned that greater public involvement in

decision-making could lead to greater unfairness in the nhS.

Figure 11: Groups also cautioned against self-selecting

public involvement

Many participants were cautious against the subjectivitythat public involvement could bring

“If the public was involved it would be total chaos”(Older, local needs group)

Engagement with the public should be random and not fall victim to members of the public with a vested interest

“People think about their own situations, people are selfish”(Older, national standards group)

Hence, unless well managed, people concerned that public involvement will jeopardise fairness - however it is defined

Ipsos Mori


26

This broadly reflects the wider concern of policymakers that

aiming to increase levels of public involvement in healthcare runs

the risk of the unwarranted influence of interest groups that could

lead to distortion in the fair allocation of resources.

information not involvementThe discussion groups broadly reflected the view that availability of

information about why decisions are made is more important than

public involvement in the decisions themselves.

Figure 12: information and transparency are more important

than involvement per se

This is a useful insight for policymakers. The views expressed

in the discussion groups may well be more measured than

public reaction to local service reconfigurations (notably hospital

closures), but they do indicate that a middle ground needs to

be found between expecting the public to play an active role in

allocating healthcare resources and ignoring their involvement

entirely. it is important that the public is kept well informed about

any reconfiguration decisions, and the reasons for such a decision

Ipsos Mori

Information, clarity and transparency counteract cynicism “If you don’t feel involved in something, it’s like somebody’smaking every decision on your behalf. It feels like a military state” (Older, local needs group)

All of the people we spoke to found it easier to accept tough decisions if they were privy to the rationalebehind them

Without information, there is a tendency for scepticismabout the basis for such decisions

“If they said why they were doing it, for whatever reason, then people would generally understand”(Younger, local needs group)


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are carefully explained. This is still a significant communications

challenge, as it is not straightforward for government or healthcare

commissioners to capture the attention of local people when

decisions are made. however, it is important that rigorous attempts

are made to explain the rationale for unpopular decisions rather

than simply seeking to mitigate the impact of a negative public

response.

MeetinG SHortFallS in HealtH BuDGetS

it is clear that the public finances have entered a period of crisis.

The iMF has estimated that the recession in the UK will be perhaps

the worst in the developed world, with a drop in GdP of 4.1% over

2009, and a continued shrinkage in 2010.17 as well as this severe

recession, levels of public debt have increased substantially, and

this will severely hamper the government’s ability to invest in

public services. The 2009 Budget confirmed that public spending

will rise by only 0.1% annually in the period 2011–14, and such is the

scale of the current crisis that similar levels of austerity should be

expected in the years beyond 2014.

in short, there is no prospect of the type of spending increases

that the nhS has enjoyed in recent years. in this context, it is right

to engage with the public to understand how decisions should be

made about funding health services. This may involve introducing

some unpalatable policy options. if the nhS is not to severely

decline in quality, the essential choices are:

• pay more in tax;

• raise more money from other sources;

• spend existing budgets more effectively and efficiently.

17 h.Stewart, “Budget 2009: iMF contradicts darling’s claim That Growth is around the corner”,

Guardian, 22 april 2009


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our quantitative work shows that a majority of people would,

unsurprisingly, rather not see tax increases or the introduction of

patient charges into the nhS. roughly two-thirds of those questioned

would rather see existing budgets spent more effectively, with

decisions made either by the government or by the nhS.

Figure 13: the survey findings

While there is a clear consensus in favour of some form of

prioritisation, it is less clear what this means in practice. our

qualitative work was therefore devoted to exploring what people

understand by priority-setting in healthcare, and what significance

they attribute to who leads prioritisation.

what is prioritisation?There were very different views between the groups about

the implications of prioritising spending on healthcare. These

differences were largely related to age, rather than to the national/

local attitudinal split explored above.

For younger people, prioritisation relates to tough choices,

about what services should or should not be provided. But older

The survey �ndings... How should NHS budget shortfalls be addressed?


73%

4%

Don’t knowTaxation should increase

NHS shouldprioritise

Individuals shouldcontribute

20%20%

5%

54%

Government should prioritise

29%

30%

10%18%

13%


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people preferred to view prioritisation as efficiency savings that

allow the current levels of service to be maintained: these two

views of priority-setting cannot be reconciled – people have

divergent understandings of what the phrase means. This has

significant implications for communication strategies to inform

people about service reconfigurations that will be necessary to

save money in the future. The public cannot be assumed to have

the same views about service reconfigurations. Some groups may

well even welcome closures if it can be shown that this reflects

a rational approach to resource allocation. others may be more

inclined to accept the downgrading of certain services in order to

raise efficiency – getting more for the same money. This is a subtle

but important distinction.

Figure 14: views on ‘prioritisation’

what do people mean by efficiencies? older people had strongly developed ideas about where savings

could be made, largely centred on not wasting nhS resources on

things that they viewed as trivial. central to this is the idea that it is

everyone’s duty to use the health service responsibly – not wasting

73%

4%

Ipsos Mori

28%

30%

10%18%

13%

For younger people

prioritisation = deciding which services and treatments should/ should not be provided

felt that this was necessary and justifiable

For older people

prioritisation was not about deciding which services should/ should not be provided

prioritisation = ‘efficiencies’

But different groups meant different things by this

Most people said prioritisation was the best option


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nhS time on minor matters, or misusing services by failing to turn

up for appointments.

Figure 15: what did older people mean by “efficiencies”?

interestingly, older people were willing to consider patient

charging as a mechanism to avoid inappropriate use, and to

maintain the nhS for treating serious conditions. This fits with

another broad distinction between younger and older people –

the extent to which decisions are clinically based or determined

by a calculation of the most efficient use of resources. Figure 16

explores some of the underlying values that informed whether

participants thought that priorities should be set by government

or by the nhS.

This might mean that we can develop efficiency savings that

are acceptable to different groups – closures of some ineffective

services coupled with incentives to avoid unnecessary treatment,

for example. in a resource-constrained environment, it will be

necessary to make savings that are congruent with the values of

service users. This distinction between a preference for savings

based on encouraging responsible usage and those based on

73%

4%

Ipsos Mori

28%

30%

10%

18%

13%

Not wasting NHS resources on things they see as trivial

See a social and collective responsibility to maintain the NHS - public responsibility as well

- charging for GP appointments and minor/ affordable treatments - This will discourage people using the NHS except where really needed

Hence, while they rejected language of “prioritisation”, theye�ectively did prioritise expensive, live-saving treatments

- “If they start charging for the minor stuff, they can put the money towards the big stuff” Group 1 - “I’m just thinking, anything that’s minor you pay for, but anyone with on-going serious problems like cancer, it’s funded” Group 1

But prioritisation was on a di�erent basis from what might be expected

- not “what’s most effective?” but “what’s most important?”


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cancelling services means that different groups will require

different information to legitimise the tough choices made by local

health commissioners.

Figure 16: who should make the priority decisions: government or

nHS?

Government or nHS, clinical- or resource-driven efficiency savings?We have found that public views about priority-setting in the

nhS are varied and reflect different values. There are important

implications for policymakers, notably in challenging the

assumption that an “independent” nhS would be more acceptable

to the public than one in which politicians continue to play a key

role.

• The public can accept that healthcare resources are scarce,

and that difficult decisions must be made. This contrasts with

the political rhetoric on all sides that continues to promote

the idea of the nhS as a free, virtually unlimited service.

73%

4%

Ipsos Mori

28%

30%

10%18%

13%

Older people tended to saythe NHS

Depth - understand the clinical implications

Clinical priorities

Subjective

Younger people tended tosay the government

Breadth - understand the national picture

Accountable

Objective

Focus on clinical importance

Focus on distribution of resources


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• The public is not in favour of decision-making left wholly

in the hands of the nhS. This runs counter to the position

of the BMa and other medical organisations which

have strongly argued against what they term “political

dabbling” in the nhS.18

• Government and local healthcare commissioners may be

able to build on the public view that the nhS is a precious

resource that should be used responsibly to introduce

certain charges, or discourage certain healthcare-seeking

behaviours that jeopardise the ability of health services

to perform their most important functions – dealing with

serious and ongoing disease. This becomes an ever more

important priority as public sector funding is cut in the

years to come.

concluSionSWhat can we learn from this exploration of public views about

the nhS? it is clear that there are both age-related and attitudinal

differences in views about variation, involvement and possible nhS

funding options.

age-related differencesFigure 17 illustrates some of the views about the future expressed

by our younger and older groups.

it is important that the public’s views inform the political

debate about the future of healthcare in a time of recession.

• Politicians should be open and honest about the likely

impact of the current recession on the long-term finances

of the nhS. People are more willing to accept change

if they feel that decisions made are fair, and honestly

presented.

18 BMJ, An independent NHS, 12 May 2006: www.bmj.com/cgi/content/full/334/7601/0


33

• Government should explore further the possibility of

introducing some limited nhS charges to reduce demand

if it can be shown that this will not have a negative impact

on the health of the population or challenge the principle

of equal access for equal need.

Figure 17: there is an age effect in people’s view on the future

on the nHS

Differences in attitudes towards local variationThis research also identified the core values that inform attitudes

about local variation and national standards in the nhS.

in considering the different attitudes outlined above, it is

important to remember that the groups in both categories, when

given an exercise in allocating health resources, created what

many people would describe as a “postcode lottery” – a situation

in which better specialist health services are available in areas of

particular need. This implies that the conventional view that the

public will not accept local variation in healthcare (reflected in

media uproar about access to certain treatments) actually conceals

a more nuanced view about the necessary trade-offs between

equity and efficiency.

Ipsos Mori

28%

Younger people Older people

18%

13%

Tended to think that the NHS isgetting worse, the future is bleak

Privatisation was a concern - fear of “losing” the NHS

Less comfortable with the language of “prioritisation”; talk more about “e�ciencies”

But do prioristise: feel NHS should focus more on “big ticket”services, and manage down demands for more “trivial” services

Fairly certain that the NHS wouldlook di�erent in the future but that the evolution would be neither better nor worse

Privatisation seen as a possibility, but not necessarily as negative

Comfortable with the notion of prioritisation (including some services not being funded)

But wanted this done on basis of more objective measures of clinical effectiveness


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• health policymakers should challenge the commonly

held view that the nhS is fair because “everybody gets

the same thing” and promote the idea that fairness

means that resources are directed towards health

needs as efficiently as possible, with resulting variation

between areas.

Figure 18: there is a difference in attitude towards variation

in the nHS

From idealism to realismipsos Mori has represented the views expressed in our discussion

groups on a continuum from “realistic” to “idealistic”. The ideals

of the nhS are valuable ones – healthcare according to need, not

the ability to pay. But cost pressures threaten the future of public

services. one way of increasing efficiency in healthcare is to accept

that national uniformity is far less important than services that

genuinely meet the needs of local people. We need to move in

political and policy terms from the “idealist” to the “realist” end of

this continuum.

Ipsos Mori

28% 13%

18%

Driver should benational consistency:

Fairness seen in terms of equality of service for all

Tend to focus on traditional model of ‘one national service’

More interested in public engagement

Equate targeted services with discrimination

Driver should be local targeting:

Fairness seen in terms of matching service to need

Tend to focus on objective measures of clinical effectiveness

Less interested in public engagement

Equate national consistency with mediocrity


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what have we learnt?The research described above has sought to explore what the

public thinks about geographical variation in health services, public

involvement in resource-allocation decisions and future funding of

the nhS. although there is still a consensus in favour of a nationally

based nhS, this analysis shows that, in fact, the public supports

locally tailored services, and that the key to allaying people’s

concerns about service change is transparency in decision-making

and a guiding principle of fairness. as we move into a time of severe

financial constraints, and further along the road to a truly local

nhS, these insights will prove helpful as a guide for policymakers.

These results will also inform the final recommendations of the

forthcoming SMF health Project.

Figure 19: So what does this all mean?

4%

28%

30%

10%18%

Attitudes on the future of the NHS vary on a continuum

Realists Idealists

AttitudeLocal need

AttitudeNational standard

Age younger Age older

Persuaded by clinical evidence

(effectiveness)

Persuaded by clinical importance(”big ticket” items)

Prioritisation finite resources

Prioritisation the besttreatment for everyone

Public involvementnot sure if it’s the

answer - decisions should be based on

objective evidence

Public involvementmore supportive - butmain driver should beneeds of individual

......

ipsos Mori


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Should the nHS be based on local need or national

standards?

• all responses were driven by a notion of fairness, but

this principle is interpreted differently.

• around 75% of people say they prefer national

standards, yet nearly everyone proposes local variation

when considering how resources should be allocated.

• concern over “postcode lotteries” is more subtle than it

first appears, and does not mean that people want the

nhS to be the same all over the country.

Does the public want to be more involved in

decision-making?

• Greater involvement is popular in principle, but is

difficult to achieve in practice.

• The public does not want to be consulted on

everything – the focus should be on services that

affect large numbers of people or require general

public buy-in to be successful.

• if there is objective clinical evidence about where to

allocate resources, then the public is happy not to be

involved, but wants to be kept informed.

• There is concern that greater public involvement leads

to greater subjectivity and the unfair dominance of

vested interests.

How do people want to deal with potential shortfalls

in health budgets?

• Most people favour “prioritisation”, but mean different

things by this.


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• For some, it’s about a clinical assessment of where

money can best be spent.

• For others, it’s about focusing more on expensive

medical treatment and less on common or less serious

conditions.

• There may be some public appetite to introduce

charges for less serious conditions, or to discourage

people from seeking unnecessary treatment.


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39

Kindly supported by

The move towards greater local autonomy in the NHS offers new possibilities for services

that are specifically targeted at local needs. Locally varied services will be necessary

to make the health service more effective and efficient in the years ahead. But there are

fears that greater local spending and decision-making power will undermine the national

character of the NHS, amid public concern about ‘postcode lotteries’. This study presents

the findings of a piece of original research carried out in conjunction with Ipsos MORI

examining public views about variation in the NHS. Will people respond more positively

to variation in services if they feel they have control over the decisions that are made in

their area? What accountability mechanisms should be introduced to make sure that the

health service meets public expectations? And who should take the lead in making tough

decisions about possible service cutbacks?

These questions have been made even more urgent by the dramatic downturn in the

economy. Real-terms cuts in public service budgets are now unavoidable and will present a

huge challenge for health services at a time when health costs are rising. This study shows

that while people say they are in favour of a nationally based NHS, in practice the public

supports locally tailored services. The key to allaying people’s concerns about changes to

local services is making sure that decisions are transparent and fair.

This report is part of the ongoing SMF Health Project.

£5.00 Social Market Foundation11 Tufton Street | Westminster | London SW1P 3QBPhone: 020 7222 7060 | Fax: 020 7222 0310 www.smf.co.uk David Furness and Barney Gough


LOcAL cONTROL ANd LOcAL vARIATION IN

THe NHS

SMF Health Project

Local Control and Local Variation

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Transcript of Local Control and Local Variation